4 Acknowledgements I owe thanks to many people who have helped and supported me throughout the dissertation process. First of all, I thank the members of my dissertation committee for guidance and help. I would like to address special thanks to Stefan Röpke. I could not have asked for a more respectful and kinder advisor. Many thanks also to my supervisor Babette Renneberg, who supported me throughout the process of my dissertation and gave me many possibilities to develop ideas and writing skills through collaborative projects. I thank Michela Schröder-Abé, for being a good friend and advisor all these years. I also thank Astrid Schütz for supporting me during my time as her research assistant and for building up my confidence to develop my own ideas. Without her support I probably would not have started a career in research. I thank the Cluster Languages of Emotion and the Charité Berlin for supporting this thesis. Moreover, I am grateful to all members from my Graduate School of the Cluster Languages of Emotion for insightful discussions beyond psychology. Getting familiar with methods in various scientific fields did not only broaden my scope, but also challenged my approach to research and psychology. Moreover, many thanks go to my friends, Daniela Klaus, Christian Kaufmann, Franziska Tröger, Ayat Najafi, Barbara Fragogna and Anne Weigand. Finally, but for sure most important, I address thanks to my family Guntram and Steffi Vater for supporting me all these years. I especially thank my father for the great moment we had when he detected that dissertation means that I am actually working on my PhD after two years of having started it. Although I know that it was not easy for both of them to understand what I am doing, I am thankful that they tried and built up a strong fundament for becoming who I am. Thus, this work is dedicated to my parents. IV

8 Chapter 1 Reflections in a Cloudy Pond Chapter 1 Reflections in a Cloudy Pond Introduction The following headline appeared in New York Times one year after I started working on this dissertation: Narcissists, much to the surprise of many experts, are in the process of becoming an endangered species. Not that they face imminent extinction it s a fate much worse than that. They will still be around, but they will be ignored. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM- 5) has eliminated five of the 10 personality disorders that are listed in the current edition. (November 20 th, 2010). Moreover, the German newspaper Süddeutsche announced: Welch eine Kränkung für Narzissten: Gemäß dem neuesten Stand der Forschung gibt es sie in ihrer Reinform gar nicht! [What an offence for narcissists! According to the current status of research, they don t exist as prototype!] (July 10 th, 2011). However, it is likely that Narcissistic Personality Disorder (NPD) will be retained as an autonomous disorder in the upcoming DSM-5 (e.g., Miller et al., 2010; Ronningstam 2011; Alarcon & Sarabia, 2012) (dsm5.org). Readers may wonder why this diagnosis was supposed to vanish from DSM-5. Two main arguments guided the planned deletion of NPD: The first argument was NPDs restricted attention in research agendas (see Kendler et al., 2009; Pincus, 2011). Much to a surprise of scientists from different fields, research on NPD stagnated in the late 70s. According to a search with the database PsycINFO, only twelve peer-reviewed articles (note: excluding case studies, commentaries and reviews) were published on NPD within clinical psychology from 2002 to 2012 (keyword data base search, 1 st of June 2012). NPD appears to be one of the least studied personality disorders (Boschen & Warner, 2009). Most of these studies at hand used mixed samples or non-clinical controls to explore common features of NPD. According to critical voices, this lack of research reflects rather restricted importance of NPD in clinical settings (e.g., Krueger, 2010). The second argument for deletion of NPD 1

9 Chapter 1 Reflections in a Cloudy Pond pointed to severe construct problems of the diagnostic category (Pincus, 2011) - including low to moderate prevalence rates, inconsistent internal consistencies, moderate stability over time and inconsistent discriminant validity. Referring to these issues, I want to conceptualize NPD as a reflection in a cloudy pond, a metaphor taken from the Ovidian narrative of Narcissus 1 that captures the highly variant and blurred symptom catalogues currently used in the description of NPD. Narcissistic Personality Disorder as Reflection in a Cloudy Pond Why Narcissistic Personality Disorder is a Disorder in Flux Havelock Ellis first introduced narcissism as an autoerotic disorder in Afterwards, psychoanalytic theorists subsequently contributed to the popularization of narcissism as a clinical phenomenon (e.g., Freud, 1914). Clinical theorists agreed that narcissism is a normal aspect of self-development (Kohut, 1977; Kernberg, 1998). Within this conceptualization, individuals have narcissistic needs that require age-appropriate provisions to maintain selfcohesion. In contrast, pathological narcissism is thought to emerge from a defect in the normal development of the self, which results in an inability to establish a stable sense of self. Due to the frequent use of pathological narcissism as clinical syndrome by psychoanalysts, NPD was introduced in DSM-III (1980). Since then, criteria for defining NPD were constantly in flux. The introduction of NPD in DSM-III reflects a bottom-up process: Especially psychoanalytic case descriptions guided the initial establishment of NPD criteria. In DSM-III, the set of criteria included intrapersonal (i.e., grandiosity or uniqueness, fantasies of unlimited success, exhibitionism, reaction to criticism) and at least two interpersonal disturbances (i.e., entitlement, exploitativeness, lack of empathy, idealization devaluation) (see Cain et al., 2008 for a review). 1 Ovid s Metamorphosis (written 1 A.C.E) describes the myth of the nymph Echo who tragically fell in love with the young and beautiful Narcissus. Narcissus rejects her love and is deemed to admire his own reflection in water. After his death, a narcissus flower remains in his place. 2

10 Chapter 1 Reflections in a Cloudy Pond Several changes were performed from the initial announcement of NPD in DSM-III to the latest definition of NPD in DSM-IV-TR (APA, 1994; APA 2000). First of all, vulnerable criteria (e.g., reliance upon external feedback from others to manage self-esteem, shame in response to narcissistic injury) were deleted and grandiose criteria (e.g., arrogance, selfabsorption and a sense of entitlement) were emphasized (Gunderson, Ronningstam, & Smith, 1995) 2. Vulnerable characteristics are now described in the Associated Features and Disorders section where clinicians are also cautioned that NPD patients may not explicitly show such vulnerable characteristics (APA, 2000). Grandiosity and uniqueness were split into two independent criteria. Furthermore, arrogance and a preoccupation with feelings of envy were added. These changes were performed to increase the reliability of the diagnosis and to diminish existing overlap with other personality disorders (see Pincus, 2011). The current DSM-IV-TR criteria for NPD include (1) a grandiose sense of self-importance; (2) a preoccupation with fantasies of unlimited power, success, brilliance, beauty, or ideal love; (3) a belief of being special or unique and that he or she can be only understood by, and should associate with, other special or high status people or institutions; (4) requiring excessive admiration; (5) a sense of entitlement; (6) interpersonal exploitativeness; (7) a lack of empathy; (8) envy of others or the believe that others are envious of him/her; (9) and arrogant, haughty behaviors or attitudes. The proposition of several changes in the upcoming DSM-5 underline this assumption of NPD being a disorder in flux. According to the recent information on DSM-5 proceedings, NPD will be characterized by impairments in self-functioning (i.e., identity and self-direction), interpersonal dysfunctions (i.e., empathy and intimacy) and pathological personality traits (i.e., grandiosity and attention seeking). Thus, grandiose aspects of NPD remain prominent, but are complemented by the description of vulnerable aspects (i.e., self-esteem fluctuation; for an overview see Tab. 1). Notwithstanding, the current DSM-5 proposal is not yet backed 2 According to a recent publication by Pincus et al. (2009) narcissistic grandiosity (exploitativeness, grandiose fantasy, self-sacrificing self-enhancement) and narcissistic vulnerability (contingent selfesteem, entitlement rage, devaluing, hiding the self) are distinct facets of pathological narcissism. However, it has to be noted that reseachers disagree on the definition of grandiose and vulnerable narcissism. For an overview consider Pincus (2010). 3

11 Chapter 1 Reflections in a Cloudy Pond by a fair amount of empirical research on the matter (see Verheul, 2012). Why Narcissistic Personality Disorder is a Reflection in a Cloudy Pond Several studies emphasize severe construct problems with its current conceptualization in DSM-IV-TR. First, several researchers that argue for deletion of NPD from DSM-5 refer to relatively low prevalence rates in inpatient and outpatient settings, which means that NPD is the least common personality disorder (e.g., Gunderson et al., 1994). However, considering recent empirical evidence prevalence rates of NPD are apparently inconsistent: Some studies provide low prevalence rates (e.g., 0% across five community samples, Mattia & Zimmerman, 2001; 1% in the general population, Pincus & Lukowitzki, 2010; Trull, Jahng, Tomko, Wood, & Sher, 2010) or medium prevalence rates (2,3% in an outpatient sample, Zimmerman, Rothschild, & Chelminski, 2005). Inconsistent prevalence rates conjecture severe problems with the current conceptualization of the construct. The current diagnostic criteria may lack clinical validity. However, due to the issue of assumed stigmatization or an apparent lack of treatment strategies, clinicians may hesitate to diagnose NPD in inpatient or outpatient settings. According to several studies, internal consistency coefficients for NPD criteria have been acceptable, ranging from.63 to.88 (Blais, Holdwick, & Castlebury, 1997; Blais & Norman, 1997; Grilo et al., 2001; Maffei et al., 1997). However, Blais et al. (1997) noted that adjusted item to scale correlations for several NPD criteria were below acceptable values, indicating that NPD may not be a reliable diagnosis. NPD further shows rather restricted discriminant validities. Morey (1988) provided evidence that DSM-III-R NPD had the greatest diagnostic overlap in comparison to all other personality disorders (mainly with histrionic personality disorder, borderline personality disorder, and antisocial personality disorder). Moreover, Gunderson et al. (1995) reported that the rate of overlap for DSM-III and DSMIII-R NPD with other personality disorders was about 50%. However, poor discriminant validity does not seem to be a specific problem of NPD: Blais and Norman (1997) found low discriminant validity for all personality disorders. 4

12 Chapter 1 Reflections in a Cloudy Pond However, NPD was among the worst performers. In another study of Cluster B personality disorders, Holdwick, Hilsenroth, Castlebury, and Blais (1998) found that the criteria fantasies of unlimited success, belief that he/she is special or unique, and requires excessive admiration best distinguished NPD from antisocial personality disorder. Moreover, grandiosity, belief of uniqueness, entitlement and arrogance best distinguished NPD from antisocial personality disorder and borderline personality disorder. In contrast to these studies, Fossati et al. (2005) reported that DSM-IV NPD exhibited adequate discriminant validity in an outpatient sample. The two criteria that clearly predicted NPD diagnosis were: arrogant, haughty attitudes or behaviors and lack of empathy. The three criteria that were the worst predictors of NPD diagnosis were: grandiose fantasies, need for excessive admiration, and preoccupation with envy. Although the list of peculiarities is incomplete at this point, it should be sufficient for now to underline the following statement: The ways in which NPD is defined is historically in flux and lacks the provision of clear rationales for far-reaching implications in the upcoming DSM-5. In sum, NPD suffers from construct problems that suggest its description as a reflection in a cloudy pond. As it contains a relatively indeterminate set of symptoms and features, it remains difficult to fixate a clear clinical picture of NPD. Even though information on NPD is sparse and conflicting, there are some studies that emphasize the relevance of NPD in clinical settings: NPD is associated with severe impairments in psychosocial functioning (Miller, Campbell, & Pilkonis, 2011), it is characterized by a high co-occurrence rate of affective as well as substance use disorders (Stinson et al., 2008; Clemence, Perry, & Plakun, 2009), and an increased rate of suicidal behavior (Blasco-Fontecilla et al., 2009; Ronningstam, Wienberg, & Maltsberger, 2008). Thus, NPD is a severe mental disorder associated with impairments in intrapersonal and interpersonal domains (for a review see Cain et al., 2008; Maccoby, 2000; Miller, Campbell, & Pilkonis, 2007; Ronningstam, 2011; Volkan & Fowler, 2009). 5

13 Chapter 1 Reflections in a Cloudy Pond How Other Fields of Research Contributed to Cloudiness The inclusion of NPD in DSM-III led to an increase in research on narcissism as trait in the field of social-personality psychology. Turning to social psychology, we encounter a different way of defining narcissism. Clinical psychology defines Narcissistic Personality Disorder as categorical diagnosis (mainly assessed with diagnostic interviews). Social-personality psychology conceptualizes narcissism as personality trait (mainly assessed with questionnaires, such as the Narcissistic Personality Inventory by Raskin & Hall, 1988). Thus, it is described as dimensional rather than a taxonic expression. Yet, the overlap between these different conceptualizations remains unclear, which leads to further utterly cloudy definitions of narcissism. The following Figure 1 summarizes definitions and assessments of narcissism within different fields of psychology. Figure 1. Definition and Assessment of Narcissism in different scientific fields Clinical Psychology and Psychiatry (pathological) narcissism defined as personality disorder categorical assessment Nine diagnostic criteria (mainly) assessed with structured interviews: grandiosity, fantasies, belief of uniqueness, need for admiration, entitlement, exploitativeness, lack of empathy, envy, arrogance personality trait personality disorder Social and Personality Psychology (normal) narcissism defined as trait dimensional assessment Personality trait (mainly) assessed with self-report questionnaires. e.g., Narcissistic Personality Inventory subscales (Raskin & Hall, 1988): authority, selfsufficiency, superiority, exhibitionism, exploitativeness, vanity, entitlement 6

14 Chapter 1 Reflections in a Cloudy Pond Even though the definitions and assessments of narcissism differ between these various disciplines, researchers from social psychology heavily rely on clinical theories when establishing hypotheses or interpreting research findings. In previous publications, crossreferencing is a common practice. This poor calibration between clinical psychology/psychiatry and social/personality psychology goes along with inconsistent usage of the term narcissism and may partly contribute to confusions surrounding the conceptualization of NPD (Cain, Pincus, & Ansell, 2008; Pincus & Lukowitski, 2010). In contrast to findings on negative outcomes of NPD, results of studies from socialpersonality psychology suggest that the adaptive outcome of narcissism in non-clinical samples is rather controversial. On the one hand, non-clinical individuals high in narcissism manage to generate high levels of positive affect and carry high explicit self-esteem in comparison to individuals low in narcissism (Morf & Rhodewalt, 2001). On the other hand, narcissism is connected with self-enhancement (Campbell, Reeder, Sedikides, & Elliot, 2000), illusions on attractiveness and intelligence (Gabriel, Critelli, & Ee, 1994), contingent and instable self-esteem (Zeigler-Hill, Clark, & Pickard, 2008) and interpersonal costs (Campbell, Green, Wood, Tesser, & Holmes, 2008). Furthermore, individuals high in narcissism show counterproductive workplace behavior (Judge, Piccolo, & Kosalka, 2009) and receive poor performance ratings from supervisors at work in comparison to others (Blair, Hoffman, & Helland, 2008). In sum, inconsistencies regarding the definition and the assessment of narcissism within different disciplines lead to confusions surrounding the construct narcissism. Towards Reflections in a Clear Pond: Research Agenda The focal point of this thesis was to contribute to a comprehensive understanding of NPD. The first aim of this thesis was to investigate grandiose self-esteem in patients with NPD (Study 1, Chapter 2). This relates to the first diagnostic criterion in DSM-IV-TR grandiosity. By definition, NPD is characterized by a grandiose sense of self (APA, 2000). One question that inspires enduring debates is whether narcissistic grandiosity reflects exaggerated ego 7

15 Chapter 1 Reflections in a Cloudy Pond robustness or an attempt to mask underlying implicit vulnerability. In Kernberg s (1975) view, inadequate parenting leads to deep-seated feelings of inferiority that are accompanied by attempts to maintain positive explicit self-esteem. Consequently, narcissists possess colliding self-representations. This model was named mask model in previous publications (Bosson, Brown, Zeigler-Hill, & Swann, 2003; Jordan, Spencer, Zanna, Hoshino-Browne, & Correll, 2003). Study 1 examined implicit (i.e., automatic, not necessarily conscious) self-esteem (using an Implicit Association Test, Greenwald & Farnham, 2000) and explicit (i.e., reflected, conscious) self-esteem (using a self-report questionnaire, Multidimensional Self-Esteem Scale, Schütz & Sellin, 2006) in patients with NPD in comparison to non-clinical and clinical, non-npd (Borderline Personality Disorder, BPD) control groups. By doing so, Study 1 aimed at providing evidence how self-relevant information is processed on an implicit and an explicit level. Additionally, Study 1 investigated whether discrepancies between explicit and implicit self-esteem (i.e., high implicit and low explicit self-esteem) are related to higher narcissism scores (assessed with a self-report questionnaire: the narcissism subscale of the Dimensional Assessment of Personality Pathology, Livesley & Jackson, 2002) in patients with NPD. The second aim was to investigate the DSM-IV-TR criterion lack of empathy in patients with NPD (Study 2, Chapter 3). Even though a lack of empathy is a core feature of NPD, it is exclusively based on clinical observation. We used recent conceptualizations of empathy that distinguished between two related but distinct facets of the overall construct - cognitive and emotional empathy. Cognitive empathy captures the capacity to infer others mental states and is also referred to as mentalizing and theory of mind (Blair, 2005). Emotional empathy has an affective component and signifies an appropriate emotional reaction to another person (Davis, 1993). We included patients with NPD and compared them to clinical and non-clinical controls. By doing so, we aimed at providing evidence for the question if deviations in empathy are a specific feature of NPD. Emotional and cognitive empathy were assessed with traditional questionnaire measures, the Multifaceted Empathy Test (MET; Dziobek et al., 2008), and the Movie for the Assessment of Social Cognition 8

16 Chapter 1 Reflections in a Cloudy Pond (MASC; Dziobek et al., 2006). Study 3 concentrated on the definition of NPD as being resistant to change over time (see Chapter 4). Even though stability over time is a defining feature of all personality disorders, evidence on change in NPD is widely lacking. Study 3 tracked the prevalence and remission rates of NPD over two years. A sample of ninety-six patients with a diagnosis of NPD was recruited at baseline. Forty patients participated in the follow-up study after two years. We identified rank-order hierarchies for each diagnostic criterion by their variance in prevalence and remission rates over time. Following the suggestion by Cain et al. (2008), this thesis additionally used a multidisciplinary approach by evaluating assessment strategies implemented in different disciplines of psychology. Thus, Study 4 (Chapter 5) aimed at providing a more elaborated understanding on existing labels of narcissism that are present in the current scientific literature. The Narcissistic Personality Inventory (NPI; Raskin & Hall, 1988) has dominated research on narcissism in the field of social and personality psychology. Studies using the NPI heavily refer to clinical theories. Surprisingly, it remains unclear whether the NPI is useful for identifying pathological narcissism in patients with NPD. We used an extremegroup approach by including NPD patients and healthy controls and comparing their narcissism scores. We further investigated whether self-esteem suppressed the relationship between group membership and NPI narcissism. 9

19 Chapter 2 Grandiose or Fragile esteem. Moreover, within the group of NPD patients, damaged self-esteem (i.e., low explicit, high implicit) was associated with higher narcissistic psychopathology. Limitations: In both clinical groups we included participants seeking psychiatric treatment, which might influence explicit self-esteem. Longitudinal studies are needed to further assess self-esteem stability in NPD patients in comparison to the control groups. Conclusions: Our findings are indicative of vulnerable facets in patients with NPD (i.e., low explicit self-esteem). Furthermore, damaged self-esteem is connected to specific psychopathology within the NPD group. Implications for research on NPD are discussed. Keywords: implicit self-esteem, explicit self-esteem, fragile self-esteem, damaged self-esteem, discrepancies, narcissistic personality disorder 12

20 Chapter 2 Grandiose or Fragile Introduction According to the DSM-IV-TR (APA, 2000), narcissistic personality disorder (NPD) is characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy (Saß, Wittchen, & Zaudig, 2003, p. 781). One question that inspires enduring debates is whether narcissistic grandiosity reflects exaggerated ego robustness or an attempt to mask underlying implicit vulnerability. In the present study, we addressed a gap in the literature by providing a clearer description of the grandiose self in patients with NPD. Furthermore, we investigated whether pathological narcissism is accompanied by deep-seated feelings of insecurity; if so, this would represent a vulnerable aspect of NPD. Here, we use the term pathological narcissism to refer to a diagnosis of NPD as defined in the DSM-IV-TR (APA, 2000), and the term normal narcissism to refer to non-clinical levels of narcissistic tendencies (e.g., Miller & Campbell, 2008; Pincus & Lukowitzky, 2010; Zeigler-Hill, Green, Arnau, Sisemore, & Myers, 2010). Although no study has empirically assessed the difference between normal and pathological narcissism, most authors agree that they are associated but distinct dimensions of personality (e.g., Pincus et al., 2009). Before describing our study in detail, we provide information on implicit and explicit self-esteem. Implicit and Explicit Self-esteem Several studies provide evidence that individuals may report grandiose feelings of selfworth but simultaneously have negative attitudes about themselves of which they are unaware (Bosson, Brown, Zeigler-Hill, & Swann, 2003; Jordan, Spencer, Zanna, Hoshino-Browne, & Correll, 2003). The deliberative evaluation of the self that is assessed with direct self-report measures is called explicit self-esteem (e.g., Kernis, 2003). The automatic, overlearned, presumably non-conscious evaluation of the self is called implicit self-esteem (Greenwald & Banaji, 1995; Pelham & Hetts, 1999) and is assessed with indirect measures that infer self- 13

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